The ACA and Addiction Treatment: Necessary but not Sufficient

The Affordable Care Act has done a remarkable job of expanding the number of Americans who have insurance to cover treatment of substance use disorder. But as our research team reports in the current issue of Health Affairs, many states and treatment programs have yet to build the infrastructure needed to take best advantage of the ACA and thereby expand access to care. Our team leader, Dr. Christina Andrews, describes the challenges in this interview with NPR Marketplace.

The Hows of Marijuana Legalization

weed Americans have expended tremendous energy debating the why/why not question of marijuana legalization. In contrast, little attention has been given to the hows of marijuana legalization, e.g., would a legal industry be for-profit or non-profit? How and at what level would it be taxed? How would it be regulated? The hows matter enormously. Indeed, once they are spelled out, some people who think they are against marijuana legalization realize that they could support it, and some people who think they are for marijuana legalization realize that they don’t want it after all.

The California Blue Ribbon Commission on Marijuana Policy was set up by the Northern California ACLU to dig into the hows of marijuana legalization. The Commission is not itself going to write a marijuana legalization ballot initiative nor is it going to oppose or endorse any that are written by others. Rather, we are a mix of a think tank and a public education enterprise, encouraging the public to consider carefully what marijuana legalization might look like if it were adopted in California. Everyone is welcome to attend the public events of the Commission as well as to send in their thoughts directly through our website.

My fellow commissioner Professor W. David Ball and I were recently on KQED Forum to discuss the Blue Ribbon Commission’s work. Listening to the broadcast will give you a flavor of the issues with which Californians will have to grapple as they consider the 2016 marijuana legalization ballot initiative(s).

The Presidentification of U.K. Politics

A small but irritating sentence from the FT:

On most projections Mr Cameron is expected to win more seats than Mr Miliband, although the race is tight.

In fact, any sensible projection would have Cameron and Miliband winning the same number of seats: One each.

In the U.S. System, the nation does indeed vote on one individual versus another for the top job. But in the Westminster system you vote for a party. Unless you happen to live in his/her constituency, you do not vote for or against a prime minister at all. Further, the party you voted for can throw its PM out of office at any time and go right on governing, and even if they keep their leader, s/he has (unlike a president) little independent power apart from the party. But between the UK’s wrongheaded adoption of our tiresome televised candidate debates and the relentless focus of the press on the party leaders’ personalities, families and lifestyles (even, their eating habits), you’d think the British public are about to vote for the next President of the United Kingdom.

Why Do Political Actors Overplay Their Hands?

All in?

Time to go all in?

Ted Kennedy was an extremely effective Senator, but he correctly identified as a disastrous decision his refusal to work with President Nixon on universal health insurance. At the time, Kennedy assumed that the liberal wave that had started under LBJ (who of course created Medicare and Medicaid with Kennedy’s support) was about to become a post-Watergate tidal wave, making a much more generous health care reform package possible very soon. Imagine Senator Kennedy’s pain seeing liberalism’s subsequent retreat and enduring a more than three decade wait before a similar health policy became possible.

More recently, California prosecutors pressured Governor Jerry Brown into vetoing a 2013 legislature-passed bill that would have reduced simple drug possession from a felony to a “wobbler” (something that could be charged either as a misdemeanor or felony). The public responded the following year by overwhelmingly passing a much more sweeping sentencing reform by ballot initiative, making all simple drug possession chargeable as a misdemeanor only as well as reducing criminal penalties for a range of other crimes.

Why do political actors so often believe that they have a powerful hand when in fact they are grossly out of step with the times and would much better off accepting half a loaf while they can? The simple explanation is arrogance, but politics includes many arrogant people who also have a keen sense of whether the public is with them on some issue. Perhaps insularity is the culprit. Many political actors live in an echo chamber that makes them overestimate the popularity of their views. If being in an information bubble makes you believe that your complete political triumph is just around the corner, why compromise?

However, Andy Sabl, who has forgotten more about political science than I will ever know, pointed out to me a flaw in the information bubble explanation: Sometimes misreading of the future drives rather than prevents political compromise. Both sides for example could be thinking “We can get much of what we want right now except for these few stinking compromise amendments, but we will wipe those out after our big win in the next election”. Of course, both sides can’t be correct that they will win big in the next election (indeed they could both be wrong), but the inaccurate expectations may make them happy to take half a loaf because they soon expect it to double in size.

If the information bubble hypothesis is wrong (or at least incomplete), another plausible mechanism is that sometimes political actors know they should compromise, but scorch the earth instead because of other incentives. For example, if you are the lead lobbyist for the California prosecuting attorneys, you may be more likely to lose your job if you say “I cut a deal because the future is against you” versus “I succeeded in influencing the legislature as I promised, but then the other side pulled an underhanded trick and used a ballot initiative, which is not something you can blame me for”.

Weekend Film Recommendation: The Prowler

vlcsnap645929

This week’s film recommendation is an unusual, disturbing film noir that has enjoyed a renaissance in recent years: 1951′s The Prowler. Made by left-wing artists who were being harassed by the House Un-American Activities Committee, it’s a dark take on class resentment, sexual repression and the ruthless pursuit of the American dream.

Many film noirs feature cops who are half-witted or on the take, but The Prowler is the only one I know where the central character is both a police officer and a calculating, manipulative psychopath. Van Heflin is mesmerizing as Webb Garwood, a flatfoot who is called to investigate a report of a prowler in a wealthy neighborhood. The call comes from Susan Gilvray, played with vulnerability by Evelyn Keyes (I previously raved about her work in 99 River Street). Webb lusts for Susan immediately, not just physically but also for her and her husband’s obvious status in society.

Susan is both flattered and scared by Webb. Sensing her ambivalence, he pays her several more visits until the lonely and repressed Susan gives in to his advances. Eerily, their liaisons are accompanied by the sound of her husband’s voice, a radio announcer who works at night. Webb now has the wealthy man’s wife that he wanted, but he knows he doesn’t possess her completely, nor does he have access to the money he wants to buy his own place in the world. But if her husband were out of the way, who knows what might be possible?

In terms of establishing character and framing the plot elements, the script of The Prowler is one of the best in noir. The screen credit went to Hugo Butler, but Dalto Trumbo wrote much of the script. He was blacklisted and couldn’t be acknowledged publicly as a screenwriter, but in what was probably an inside joke at the expense of the McCarthyites, he provides the voice of Susan’s husband on the radio (again, uncredited). Anyone who wants to learn how to write strong scripts should watch the scene early in the movie in which Webb and Susan discuss their experiences growing up in Indiana. As Webb explains how he blew his chance to get a college education, the audience understands immediately his smallness as a human being and his entitled rage towards people whom he tells himself have denied him what he deserves.

The film also demonstrates something many producers forget: Characters don’t have to be likable, they just have to be interesting. Neither of the principals are people you’d want as your neighbors, but it’s extremely compelling to follow the tenebrous twists of their relationship.

The direction, by the soon to be blacklisted Joseph Losey (probably best known for the thematically similar The Servant), is unusual and effective. He structures the scenes in play-like fashion, with long takes in just a few key, evocative sets. Those locations each have their own vivid bleakness, especially the ghost town in which the third act occurs. Congratulations are due to Art Director Boris Leven and Set Designer Jacques Mapes for tremendous work on a small budget.

The film suffers slightly from a lull between the first and third acts as well as some plotting improbabilities, but it’s still a bit surprising that it wasn’t more of critical and popular hit upon release. It may have been a bit ahead of what a 1951 U.S. audience wanted to see in a story focused on a police officer. It was however very popular in Europe, where Losey was soon to flee to escape political persecution. Later, the film was reappraised by U.S. film noir devotees and its reputation has deservedly grown.

The Prowler is in public domain, so I am posting here a watchable version that someone seems to have videotaped off television. There is also a remastered version by UCLA’s vaunted restoration team which no doubt looks even better if you can find it.

p.s. Interested in a different sort of film? Check out this list of prior recommendations.

The Smokers We Treat vs. Those We Study

The profile of the smoking population in the developing world has changed dramatically in recent decades. The era when smoking was normative among adults is gone, to be replaced by one in which those people still smoking tend to be low income and/or have mental health and alcohol/drug problems.

You might think that this new world of smoking would lead smoking cessation researchers to focus intensely on how to help smokers who have comorbid problems. But as my colleague Anna Lembke and I describe in the current issue of Tobacco Control, just the opposite is true:

One review of the smoking cessation trial literature found that 40% excluded depressed smokers, 55% excluded smokers with alcohol use disorders and 59% excluded those taking psychiatric medications. One critic described the practice of excluding smokers with mental health issues as a ‘scandal’, which is reasonable given the stunning 62% rate of smoking among people with schizophrenia, the 42.6% rate of binge drinking among all smokers, and the enormous tobacco-related health damage in the seriously mentally ill population.

Smoking cessation research is one of too many cases where the science that is supposed to guide medical practice for all patients is generated primarily by studying relatively healthy, wealthy, happy and young research subjects. A scandal indeed.

The Eurozone’s Inbuilt Compassion Deficit

The Euro is the Windows 8 of the economic policy design world: In both cases, it’s very hard to understand how putatively smart people worked so hard to create a product so ill-suited to the needs of those who were supposed to rely on it.

That’s yours truly writing at Mother Jones about another way that the designers of the Euro seemed not to understand basic principles of human psychology (not that they grappled honestly with basic economic principles either). I have written before about other psychological failures of the system, in this case I am referring to the false assumption that all Europeans have a strong shared sense of identity which would generate compassion rather than screw turning in hard economic times.

You can read the whole piece here. Far more important than my Euro-ramblings is this: For the next two months that learned knight of the blogosphere, Kevin Drum, will go through the final phase of his cancer treatment. While he is recovering, a passel of bloggers who admire him will be filling in at Mother Jones, so you can keep watching his column with an expectation of blogging activity and I hope also an occasional update on how Kevin is coming along. My best wishes to Kevin and his wife (and also of course, their cats).

Weekend Film Recommendation: D.O.A.

doa-nightmare

Last week, I recommended The Turning Point, starring Edmond O’Brien and featuring Neville Brand in a small part as a vicious killer. For a change of pace, this week I recommend a film starring Edmond O’Brien, featuring Neville Brand in a somewhat larger part as a vicious killer: 1950′s D.O.A.

D.O.A. has one of best opening premises in the history of film noir. A man stumbles down an impossibly long, shadowy hallway at the police station, followed by a tracking camera. Upon meeting the officer in charge of homicide investigation, he announces that he wants to report a murder: His own. What follows is partly a mystery/action story and partly an existential meditation.

The central character, Frank Bigelow (O’Brien) has a life that screams conventionality. He’s an accountant in a small town with a small town girlfriend (Pamela Brittan) who is nagging him to do the decent thing by marrying her, settling down, and having a conventional family. This is a noir film, so naturally Bigelow wants nothing more than to flee. He goes for a wild weekend in San Francisco, where he ogles sophisticated urban beauties and swills liquor until for an inexplicable reason, someone covertly poisons him with a lethal, slow-acting toxin. After the terminal diagnosis is confirmed, s justly famous film noir sequence commences as Bigelow races madly through the crowded streets until, exhausted, he looks up to heaven and then down to see a little girl’s ball at his feet. He returns the ball to the girl and then sadly stands up, knowing that he will never be carefree as a child again for he is doomed to die, and very soon at that (Nice touch: Look at the particular magazine arrayed next to him in the shot above).

Although Bigelow cannot save his life, he is driven to understand why he will die, and thus spends his final precious days not enjoying what remains, but ruthlessly pursuing his killer. With his death in no doubt, he transforms from a mild-mannered accountant into a fearless, even brutal, angel of vengeance. He doesn’t fear death from the assorted villains he encounters, just the prospect of dying before he can find out why a nobody accountant from a nothing small town was worthy of cold-blooded, calculated murder.

As you would guess, D.O.A. offers much to chew on thematically. It can be enjoyed at one level as an exciting (if overly complicated) crime mystery, but at another level it’s a philosophically engaging take on venerable film noir themes of isolation, futility and the cruelty of fate.

Director Rudolph Maté earned his place in movie heaven as a cinematographer, including in my prior recommendations Vampyr and Gilda. He directed much less often, and that’s a good thing because he didn’t attain the same level of excellence in that role. Here, he allows some of the actors to go over the top too often, and there is also an embarrassingly puerile use of a “Va Va Voom” sound effect when O’Brien sees attractive women that is completely inconsistent with the noir mood.

I would say I wish Maté had been director of photography instead, but that wouldn’t be fair to Ernest Laszlo, who gives the film a stunning look, especially in the street scenes in San Francisco and Los Angeles. The crowded street shots must have been particularly challenging from a technical viewpoint.

DOA10Neville Brand, in a role that helped make his fairly successful if completely typecast career, is admirably scary here as a psychopath, and Luther Adler makes a smooth, cultured but ultimately nasty villain. As mentioned, some of the other performances — including O’Brien’s — are uneven, but all the main actors have their moments.

The basic existential conceit of D.O.A. is not about a man trying to prevent his death; he doesn’t have that power. Rather, it’s all about the desire to know why — why me and why this fate? The best noirs never answer this question, but bathe the audience in the agony of being unable not to ask it nonetheless. D.O.A. is a noble example of this tradition.

D.O.A. is in the public domain, so you can watch it for free on Internet Archive. However, that print looks nowhere near as good as the digitally remastered version, which as of this writing is free for Amazon prime subscribers.

Weekend Film Recommendation: The Turning Point

turningIn previous recommendations (The Naked City, He Walked by Night), I highlighted the rising popularity of police procedurals after the war. Recognizing that post-war audiences were gripped by more realistic, torn from the headlines crime stories, Hollywood producers were giddy over the Kefauver Committee’s investigation of organized crime. Many Americans were transfixed by the hearings, both because they provided their first glimpse into the workings of the Mafia and because they were on this new fangled gizmo known as a television. A raft of films followed that were based on the hearings either directly or obliquely (the latter including my first ever weekend film recommendation, Bullitt). Many of the Kefauver films were cheap and unimaginative, but this week’s recommendation is one of the best: 1952′s The Turning Point.

The strong cast features Edmond O’Brien as John Conroy, a special prosecutor appointed to take down a criminal syndicate run by the slimy, brutal Neil Eichelberger (Ed Begley), who poses as a legitimate businessman (O’Brien was last with us in prior recommendation The Web). Conroy’s hard-nosed childhood pal (William Holden), now a crime reporter, comes along for the ride, not because he believes anything will come of the investigation but because he admires his old friend and also, rather guiltily, has eyes for Conroy’s gorgeous, idealistic assistant (Alexis Smith). Meanwhile, John’s father, a beat cop played by reliable veteran character actor Tom Tully, is also in the mix, but what side he’s playing is a subject of mystery.

Warren Duff never became famous as a screenwriter, but he was very good in his niche of tough crime stories. He does a particularly admirable job here creating dramatic face off scenes between each pair of principals. Lionel Lindon’s skilled camerawork makes the film pleasing to the eye (love the long tracking shot with Holden and O’Brien early on) as does William Holden, who looks fabulous in a series of tailored suits that the legendary Edith Head picked for him (I guess ink-stained wretches could afford those kind of threads and fashion advice back then). The broad-shouldered screen icon has real chemistry with his equally toothsome co-star Alexis Smith, who puts spine and depth into her character rather than just being eye candy. She and Duff’s script are particularly good at ripping apart the cynical facade of Holden’s character, which is potent stuff for Holden fans given how often he played this type.

turningpoint3The Turning Point has a few weaknesses. After a gripping first 45 minutes there is a lull in the action at the actual commission hearings, which should have been a highlight of the film, especially with a skilled actor like Ed Begley at center stage. There are also a couple small logical holes and overly worn elements in the plot. As a result, I would not call The Turning Point an all-time classic crime melodrama. But it’s definitely exciting and entertaining, with a cast that is aces right down the line.

As of this writing, The Turning Point is available for free to Amazon Prime subscribers – just don’t mix it up with the 1977 movie about ballet dancers.

p.s. Plug ugly Neville Brand, who made a career out of playing nasty thugs, appears at the end as a hired killer. Both he and O’Brien will be with us again next week so stay tuned.

p.p.s. Interested in a different sort of film? Check out this list of prior recommendations.